Effective Prevention in HIV Care Developed by: The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education & Training Centers Module 3 Partner Services (PS)

Upon completion of training, providers who care for HIV-infected persons will be able to:  Define Partner Services (PS)  Explain the providers role in PS  Describe how to refer patients for Partner Services provided by state and local Health Departments Learning Objectives: Module 3

Breaking the Chain of Infection Clinical Management Partner Services Behavioral Counseling

Quick Poll What comes to mind when you hear the term Partner Services?

What are Partner Services (PS)?  Health Department services to assist PLWH with telling their sexual and needle-sharing partner(s) about possible exposure to HIV and other STDs  Are provided by trained, professional HD staff: Disease Investigation Specialists (DIS)  Are voluntary, confidential and free  Facilitate linkages to testing and services for partners

Rationale for Partner Services (PS) Partner Services has proven to be a very effective prevention strategy.  GOALS: to identify individuals who are unaware of their HIV and other STD status link these partners to testing, care, treatment, counseling, and other prevention resources, as needed To interrupt disease transmission and protect community health

Partner Services Outcomes  Systematic literature review of studies evaluating effectiveness of PS  9 studies included  Range of 1-8 partners identified per patient  Mean of 67% of partners found, and notified of potential exposure  Mean of 63% of those notified were tested  20% of those tested were positive  Health Department Referral Option was most cost effective Hogben et al, AJPM, Handout 6

The Argument for Prevention Through Testing and Diagnosis  20% (234,000) with undiagnosed HIV are associated with >50% of sexual transmission  80% (936,000) with diagnosed HIV are more likely to access prevention and treatment Marks et al, AIDS, 2006.; Campsmith et al, JAIDS, CDC, HIV in the United States; [Factsheet].

What Health Department Partner Services Can Provide for your Patients and their Partners For your patient:  Talk with your patients to identify partners  Discuss and determine best strategy for notification of each partner  Perform the notifications, if patient chooses  Linkage to other needed social and medical services For your patient’s partners:  Provide access to testing, linkage to care and other prevention services, if HIV positive  Provide counseling and education for reducing behavioral risks of STD/HIV transmission

How Do Patients Feel About Health Department Partner Services?  Seattle survey of persons w/recently reported HIV (80% MSM)  84% agreed (somewhat/strongly) the health department should routinely offer everyone diagnosed with HIV help in notifying their partners  20% would want help notifying at least one partner from the last six months Golden et al, JAIDS, Handout 5 & 6

Partner Services Benefits and Common Concerns  Benefits to patient  Help with disclosure to partner(s)  Fulfills ethical desires for patient  Benefits to clinician  Fulfills public health and ethical concerns  Can be performed by non- clinical staff  Common Concerns  Confidentiality  Potential for intimate partner violence  Time involved  Unclear legal expectations

Laws and Regulations A brief overview related to informing partners

Becoming Familiar with Local Reporting Requirements  STD/HIV requirements for reporting differ by state  Consult with state STD/HIV program and policy offices  Some areas also have laws and regulations about duty to inform partners of their exposure to HIV Handout 1

Local Reporting Requirements & PS Program Guidelines  Laws specific to clinicians  How Health Department staff coordinate with clinicians to provide PS  Protecting confidentiality/data security systems  Time frame for PS  Reporting of names/demographics to other agencies  Referrals from other jurisdictions for partner services  Spousal Referral

5 Partner Referral Options: At-A-Glance Type of OptionsWho notifies and refers this partner? 1) Health Department Referral Trained Health Department staff (DIS) 2) Patient ReferralPatient with coaching from Health Department staff 3) Contract ReferralPatient makes initial attempt; if unsuccessful, Health Department staff conducts referral 4) Dual ReferralPatient agrees to disclose HIV status with Health Department staff present 5) Third-Party ReferralProviders other than health department, who are trained in Partner Services Handout 3 & 6 Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection, MMWR, Oct 2008

The Provider’s Role: Referring to Partner Services  At initial visit, ask all patients whether their sex and needle-sharing partners have been informed of exposure to HIV  Briefly explain Health Department PS, and refer all appropriate patients  At follow-up visits, routinely ask patients about new partners who have not been informed of exposure to HIV  Also ask patients whether Health Department has contacted them to discuss PS CDC, MMWR, 2003.

“Now that we’ve talked about ways to keep you healthy, let’s talk about ways to keep your partner(s) healthy. How do you feel about telling your partner(s) they’ve been exposed to HIV?” How to Bring Up the Subject of Partners Handout 2

 Trained and experienced staff who provide PS and other counseling services for persons with HIV and STD, and their partners, in both field and clinic settings  DIS training includes strong emphasis on confidentiality  No information about your patient is ever given to the partner  Rapid notification is the goal (usually hours)  Trained to handle intimate partner violence and difficult relationship situations  Relieves you and your staff of those duties Who are DIS, and What Do They Do? Handout 4

Explaining PS to Patients “The health department has special staff who can help you decide about the best way to let your partners know that they need an HIV test.”  Clarify misconceptions  Free and confidential  If patient is hesitant: “I think I can tell them all myself ”  Explain that DIS can help practice how to do this  Check in at next visit Handout 2

Partner Services: Trained DIS in Action  Clinicians often ask how DIS notify partners  Video demonstration of a Health Department DIS confirming the identity of a partner

Video demonstration of a DIS notifying a partner of her exposure to HIV Partner Services: Trained DIS in Action

Core Messages for Patients  Partner Services is a Health Department program  Helps patients decide how to inform partners of possible exposure to HIV  Provides a trained DIS who can notify partners without ever mentioning the original patient’s name or other identifying information  PS is a confidential service that a person elects to use  This is a free and ongoing service that can be accessed at any time

Skills Practice GOAL: To enhance comfort with bringing up the subject of partners, and discussing the value of using the health department PS to notify partners  Use 5 minutes to practice bringing up the subject of partners, and discussing how the health department can help your patient  Then stop, switch roles, and take an additional 5 minutes to practice

Skills Practice: Group Processing  What were the “sticking points”?  Were there any questions posed by the “patient” which were a challenge to answer?  CDC Fact Sheet for PS:

PS In Action: “Real Life”  A 22 year-old male tests HIV-positive in a correctional setting  PS is offered and he names 3 women  Two partners were notified (a 19 year-old, and a 20 year-old)  Third partner was “un-locatable”  Both elected to test for HIV & both were positive

 The 19 year-old  Named the original patient and said he was her only lifetime partner  She entered an Early Intervention Program  No risk factors other than unprotected sex  The 20 year-old  She was leaving the area to attend college when she received her positive test result  Notified her female partner in the presence of PS provider (Dual Partner Management Option)  She also entered EIP and returned annually for care “Real Life” - The Partners

 After being released from prison, he names 3 additional partners at an EIP session  1 of the 3 new partners was a 16 year-old girl who had recently given birth to his child  PS providers were unable to locate these 3 partners In Summary  Confidentiality was maintained for all patients and their partners  Multiple jurisdictions were involved  2 of the 3 initial partners for the male were found and neither would otherwise have suspected they were infected “Real Life”- Back to the 22 Year-Old Male Patient

What is one thing you will change in your practice…?

 RISK SCREENING  STD SCREENING  PREVENTION MESSAGES  ADDRESSING MISCONCEPTIONS  BRIEF BEHAVIORAL INTERVENTIONS  PARTNER SERVICES ASKSCREENINTERVENE